on insulin, because if you are a diabetic you require insulin to function normally, and if you suddenly stop it, you will experience serious adverse consequences!
To use an example that’s more to the point, you can be dependent on opiate pain pills because you have a legitimate pain problem and you can’t function without them due to the pain. Let’s say you have metastatic cancer and you need to be on morphine to control your cancer pain. If you stop that morphine, you’re going to go into withdrawal. So you have developed an opioid dependency, but you’re not necessarily an addict—especially if you don’t exhibit compulsive out-of-control drug craving and drug-seeking. Compulsive out-of-control drug craving and drug-seeking, coupled with dependence, is the hallmark of addiction.
We can use the process of making a pickle as an analogy for how this process works. You start with a cucumber, put it in vinegar or some kind of juice, and then let it sit there. After a certain period of time the cucumber turns into a pickle. However, you can’t make it return to a cucumber again, because the composition has been chemically changed. A chemical reaction has occurred and it’s no longer a cucumber; it’s now a different vegetable, a different substance—a pickle. Similarly, when someone has the disease of addiction, as much as he or she might wish to, returning to “controlled” drug use is not an option.
I’ve heard people say things like: “I abused alcohol when I was in college and now I’m fine; I am able to drink normally now.” I would argue that this person was never really an addict; that he went through a period of life during which he abused alcohol, maybe was going through a divorce, perhaps had a stressful job, and self-medicated, i.e., “drank too much.” But he never turned from a cucumber into a pickle and didn’t meet all of the criteria for addiction.
There have always been addicts. Depictions of intoxication and addiction occur throughout history, from the Greco-Roman period, through the Middle Ages, during the Industrial Revolution, and so forth. There have always been people who couldn’t control their use of mind- and/or mood-altering substances.
In 1914, the United States government passed the Harrison Narcotic Tax Act, which essentially criminalized opiate/narcotic drug use. The government position was that alcohol and other drug problems were not medical problems, but rather issues for the police and law enforcement. Then came the Drug Enforcement Administration and the ever-expanding criminalization of addiction—to the point where doctors were actually arrested for the “crime” of treating addicts. This was true right up until the late sixties when the American Medical Association finally got involved.
Some very brave people who started the Haight Ashbury Free Clinic were at the forefront of the sea change that took place when the “flower children” were going up to San Francisco, zoning out, taking LSD, and having bad trips. The police kept trying to bust the medical practitioners at the Haight Ashbury Free Clinic, saying, in effect, “This is not a job for doctors or nurses; it’s a job for the police to handle.” Finally a lot of bigwigs got involved and went to the American Medical Association, there was a big protest, and the pendulum has now swung in the opposite direction.
Now addiction is considered a medical problem, but there is still “personal choice/failure of character vs. disease” tension in America. I remember when a well-known conservative radio host used to say that we should arrest all the addicts and “send them up the river.” That was, until he became an addict himself. If you’re in recovery you may well relate to the examples that I give here. For those of you who don’t have any background in addiction, please be aware that when somebody goes down that dark road of addiction and experiences powerlessness and loss of control, it becomes a very humbling and oftentimes, a humiliating experience.
People used to say to me, “How can you know anything about addiction or how can you feel for this if you’ve never had this problem yourself?” And I always say, “Look, it’s a medical illness. I can be a good dermatologist and not have acne. I can be a good surgeon and not have gallbladder stones. So why can’t I be a good addiction physician, empathize with the patients and with what they’re going through, and not necessarily, as an important criteria, be somebody in recovery?”
Some people still say things like, “Addiction really isn’t a disease, because you guys don’t cure anybody!” Especially if the person is a healthcare professional, like a doctor or nurse, I reply to them with a question: “How many diabetics have you cured lately? How many patients with asthma have you cured recently? How many patients with high blood pressure have you cured recently?” The fact is that 90 percent of the work that doctors do involves the medical management of chronic illness. Diabetes is a chronic illness. High blood pressure is a chronic illness. Asthma is a chronic illness. For a lot of people, low back pain comes and goes and is a chronic illness. Headaches are a chronic illness. Arthritis is a chronic illness.
Most treatments in medicine today involve management of chronic illnesses. Sure, if somebody breaks his or her arm that’s an acute episode, and if somebody gets pneumonia he or she might require a hospital stay as well, so acute illnesses obviously occur. But the majority of what goes on in everyday medical practice is management of chronic illness.
I think diabetes is a wonderful model for addiction. Diabetes mellitus (sometimes called “sugar diabetes”) is a condition that occurs when the body can’t use glucose (a type of sugar) normally. Glucose is the main source of energy for the body’s cells. The levels of glucose in the blood are controlled by a hormone called insulin, which is made by the pancreas. Insulin helps glucose enter the cells as fuel, or food.
In diabetes, the pancreas does not make enough insulin (type 1 diabetes) or the body can’t respond normally to the insulin that is made (type 2 diabetes). This causes glucose levels in the blood to rise, leading to symptoms such as increased urination, extreme thirst, and unexplained weight loss. For people who don’t have enough insulin or can’t respond normally to insulin, the sugar in the blood stays very high because it can’t get into the cells to be metabolized (burned).
High blood sugar is toxic to many organs in the body. It’s toxic to the eyes and causes people to lose vision. It’s toxic to the blood vessels, people get heart disease, and can lose their feet to amputation because they don’t get proper blood circulation. They lose kidney function, they go into renal failure, and so on.
Type 2 diabetes is milder. People with this type may just have to take medication, increase their exercise, and adjust their diet. Type 1 is a more severe form of diabetes, which entails injecting insulin. But either way, if you have diabetes and take your insulin, take your medications, maintain your diet, do some modest to moderate exercise, and undergo what are termed “lifestyle changes,” you’ll probably go on to lead a normal, productive, and healthy life. If you don’t do those things and you remain in a state of denial and eat candy bars all day and rarely leave the couch, you’re at considerable risk of losing your vision, losing circulation to your feet, developing heart failure, and experiencing renal failure.
It’s the same with addiction. If you ignore your problem, maintain a state of denial, do not take your medications, and do not participate in treatment or support groups, you will progressively develop more and more serious adverse consequences, including a large number of medical complications, along with the potential for losing your life. On the other hand, if you acknowledge that you have a problem, take your prescribed medications, and make the necessary lifestyle changes, including support group participation, you stand a very good chance of living a normal, productive, and healthy life.
Here’s Dr. Solof’s “Two-step process,” framed for patients: Acknowledge you have a problem, and work with something outside yourself—professional resources, people, support programs, and a Higher Power, to help you do something about that problem. Of course it’s more complicated than that, but simply put, you have to stop using. You are no longer a person who can drink; you’re not a person who can use drugs. Sure, you’d like to go back to using
